Excerpt

An 84-year-old man with carotid artery stenosis and prior history of lower limb amputation was admitted with symptomatic aortic stenosis. Echocardiogram showed an aortic valve area of 0.83 cm² with a preserved left ventricular ejection fraction of 67%. Computed tomography (CT) demonstrated an aortic annulus area of 437 mm², a porcelain aorta, and heavily calcified stenotic lesions of the bilateral iliac arteries. Due to high surgical risk and poor femoral access, we decided to perform transapical transcatheter aortic valve replacement (TAVR). A 26-mm Edwards SAPIEN-XT™ valve (Edwards Lifesciences, Irvine, California) was implanted after aortographic and transesophageal echocardiographic (TEE) confirmation of appropriate valve position. However, his blood pressure did not recover even with inotropic medications after aortic valve deployment. Aortography and TEE revealed severe intravalvular aortic regurgitation (Fig. 1a, b), and confirmed that while one leaflet was mobile and functioning, another was immobile. While preparing for a second valve implantation, removal of the guidewire and post-dilation were tried, but were ineffective. Hypotension was observed to worsen, and he then developed ventricular tachycardia. Defibrillation successfully restored sinus rhythm, and his hemodynamic parameters recovered rapidly. TEE and aortography revealed adequate functioning of all valve leaflets with only a mild paravalvular leak (Fig. 1c, d). Finally, the procedure was successful without requiring a second valve implantation. Postoperative CT showed a mass of calcification located adjacent to the commissure between the two leaflets of the implanted valve. The patient was discharged home on postoperative day 18 without any sequelae.

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